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1 Manitoba Centre for Health Policy
Tuberculosis Treatment,
Prevention, and Management
in Manitoba: A Population-
Based Investigation
Lisa Lix and Pierre Plourde
(on behalf of the Deliverable Team)
Evidence to Action: MCHP’s Annual Workshop
September 26th, 2017
2 Manitoba Centre for Health Policy
Deliverable Team
• PI: Lisa Lix (MCHP)
• Co-PI: Pierre Plourde (WRHA)
• Co-I: Kathi Avery Kinew (Nanaandawewigamig/FNHSSM)
• Co-I: Linda Larcombe (U of M)
• Analyst: Andrew Basham (formerly with MCHP)
• Analyst: Shelley Derksen (MCHP)
• RC: Jennifer Schultz (MCHP)
• RS: Scott McCulloch (MCHP)
3 Manitoba Centre for Health Policy
Advisory Group• Nancy Yu (MHSAL)
• Carla Loeppky (MHSAL)
• Richard Baydack (MHSAL)
• Alison Bertram Farough (WRHA)
• Martha Ainslie (WRHA)
• Pam Orr (WRHA)
• Chastity Cleofas (WRHA)
• Debbie Nowicki (WRHA)
• Heather Adam (DSM)
• Joni Wilson (Southern Chiefs’
Organization)
• Curtis Mallett (MKO)
• Gwen Gillan (Nanaandewewigamig)
• Richard Long (University of Alberta)
• Brent Roussin (First Nations and
Inuit Health Branch)
4 Manitoba Centre for Health Policy
Deliverable Rationale• Manitoba has the highest rate of tuberculosis (TB) in Canada
amongst the provinces; it disproportionately impacts certain populations and has a large impact on health care resource use.
• A patient-focused, high-quality system of care cannot be achieved without prior information about system performance.
• No comprehensive provincial TB report currently exists that integrates information from across the various components of the healthcare system.
• This deliverable is intended to provide baseline information that will inform the work of practitioners, program/policy planners and advocacy groups.
5 Manitoba Centre for Health Policy
Deliverable Objectives
1. Validate select elements of administrative health
data and the Manitoba TB Registry relevant to TB
prevention, treatment, and/or management.
2. Characterize contacts of persons with active TB
disease and the validity of information about
contacts in the Manitoba TB Registry.
3. Describe healthcare use by socio-demographic,
comorbidity, and disease characteristics for persons
with active TB disease and who are under
treatment for latent TB infection (LTBI).
6 Manitoba Centre for Health Policy
Study Data Sources
Manitoba Population
- Based Registry
Manitoba Population
- Based Registry
Social HousingSocial
HousingEducationEducation
Healthy Child MBHealthy
Child MB
ImmunizationImmunization
Medical ServicesMedical Services
Personal Care HomePersonal
Care Home
ClinicalClinical ProviderProviderVital Statistics
Vital Statistics
ERERHealth LinksHealth Links
PharmaceuticalsPharmaceuticals
HospitalHospital
Family ServicesFamily
Services
Income Assistance
Income Assistance
CensusCensus
• DSM
• Cadham
• DSM
• Cadham
• DPIN
• In-hosp.
pharma
(Cerner)
• DPIN
• In-hosp.
pharma
(Cerner)LabLab
Manitoba TB
Registry
• ADT & E-triage
• EDIS
• ADT & E-triage
• EDIS
HomecareHomecare
• MDS• MDS
7 Manitoba Centre for Health Policy
Manitoba TB Registry
• Active TB disease is a notifiable disease under the
provincial Public Health Act (LTBI is not reportable)
• Laboratory and clinical case reports are submitted to
Manitoba Health, Seniors, and Active Living (MHSAL)
and then referred to the RHAs for follow up
• The TB Registry maintained by MHSAL captures a
variety of information about each case:
– Demographic and geographic characteristics, contact
assessment, bacteriology and x-ray results, course and
outcome of treatment, identified drug sensitivities
8 Manitoba Centre for Health Policy
Study Cohorts• Active TB Disease: Defined from Manitoba TB Registry
– Laboratory-confirmed cases: (a) Clinical specimens smear positive for acid-
fast bacilli (AFB); (b) Clinical specimens culture positive for Mycobacterium
tuberculosis complex (MTBC); (c) Pathology sample findings suggestive of
TB disease
– Clinical cases: Evidence of active TB disease but no culture proof of MTBC;
Examples of clinical evidence: x-ray, non-respiratory disease indications,
pathological or post-mortem evidence, favourable response to therapeutic
trials of prescription drugs
• Treated LTBI: builds on methodology adopted by Smith et al. (2011);
Defined from Manitoba’s prescription drug records
– Cases with latent TB infection included individuals receiving the following
prescription dispensations: isoniazid (INH), rifampin (RMP), sequential use of
INH and RMP
– Exclusions are based on selected diagnoses and combinations of
prescription medications
9 Manitoba Centre for Health Policy
Study Cohorts• Disease- and Treatment-Free Matched Cohort for Active TB Disease
Cases
– Matched on: Birth year (± 1 year), Sex, Group (First Nations/non-First
Nations), RHA based on postal code at case date
– Controls must have coverage 365 prior to case date and up to 720 days
following case date
– Cannot be active TB cases, contacts of cases, or treated for LTBI
– Selected without replacement
– Up to 5 matches for each case
• Disease- and Treatment-Free Matched Cohort for Treated LTBI
– Same criteria as above
10 Manitoba Centre for Health Policy
Overview of Methods
• Objective #1: Focuses on active TB cases
ascertained from the Manitoba TB Registry
– Data elements to validate included:
• In administrative data: TB diagnosis
• In TB registry:
– Date of death
– Demographic characteristics
– Origin group
– Diagnoses
– Treatments
– Laboratory tests
– Healthcare services: hospitalization, X-ray
11 Manitoba Centre for Health Policy
Overview of Methods
• Objective #2: Focuses on the contacts of active TB
cases ascertained from the Manitoba TB Registry
• Measures included:
– Contacts per case, described by socio-demographic
characteristics
– Contacts assessed
– Contacts treated for LTBI
– Contacts who become active TB cases
• Validity assessment:
– Socio-demographic characteristics of contacts
12 Manitoba Centre for Health Policy
Overview of Methods• Objective #3: Focuses on active TB cases ascertained
from the Manitoba TB Registry and treated LTBI cases ascertained from administrative health data
– Healthcare use measures: emergency, acute, primary, and supportive care sectors
• Before and after diagnosis date (active TB) or initiation of treatment date (treated LTBI cohort)
– Trends in healthcare use up to one year before and 2 years after TB diagnosis/LTBI start of treatment,
– Tests for differences in healthcare use by socio-demographic, comorbidity, and disease characteristics
– Tests for differences with matched TB disease- and LTBI treatment-free cohorts
13 Manitoba Centre for Health Policy
Figure 1. Study Flow Chart for Active TB Cohort
Step 1: Initial Cohort
Identify all individuals with an
index date (i.e., diagnosis date
or date of entry in the Manitoba
TB Registry) between April 1,
1999 and March 31, 2014.
N = 2,043
Step 2: Cohort
Exclusions
#1: Individuals with invalid
or missing PHINs
N = 134
#2: < 365 days of
coverage before the study
index date or < 30 days of
coverage after the study
index date
N = 223
Step 3: Final Cohort
N = 1686
14 Manitoba Centre for Health Policy
Figure 2. Study Flow Chart for Treated LTBI Cohort
(based on ± 14 days from index date for drug-related exclusions)
Step 1: Initial Cohort
Identify all individuals with a
prescription of INH or RMP
between April 1, 1999 and
March 31, 2014
N = 10774
The date of the prescription is
the index date
Step 2: Cohort Exclusions
#1: A diagnosis for leprosy ≤ 30 days before the index date
N = <6
#2: For individuals with a prescription for INH only: exclude all individuals
with a prescription for RMP, rifabutin, ethambutol, pyrazinamide,
amikacin, capreomycin, cycloserine, linezolid, moxifloxacin, para-aminosalicylic acid, or streptomycin that is ± 14 days of the index date
N = 561
#3: For individuals with a prescription for RMP: exclude all individuals
with a prescription for INH, clofazimime, ethambutol, pyrazinamide,
amikacin, azithromycin, capreomycin, cefazolin, cefotaxime, cefoxitin,
ceftriaxone, cefuroxime, ciprofloxacin, clarithromycin, clindamycin,
cloxacillin, cycloserine, dapsone, daptomycin, doxycycline, erythromycin,
flucloxacillin, fusidic acid, gentamicin, imipenem, levofloxacin, linezolid,
meropenem, minocycline, moxifloxacin, mupirocin, para-aminosalicylicacid, streptomycin, sulfamethoxazole/trimethoprim, or vancomycin ± 14
days after (and including) the index date
N = 3173
#4: Individuals with a prescription for INH or RMP up to 180 days prior to
the index date
N = 60
#5 < 365 days of coverage prior to the index date and < 30 days of
coverage after the index date
N = 583
Step 3: Final Cohort
N = 6392
15 Manitoba Centre for Health Policy
Conclusions (1)
• Manitoba TB Registry data are of good quality
• There are approximately 125 active TB disease cases and 420 treated LTBI cases each year. There is a disproportionate burden on:
– Northern Manitoba (esp <18 years)
– Lowest income groups
– First Nations on- and off-reserve
– Foreign-born
– Persons with certain comorbid conditions (HIV, renal disease, advanced diabetes)
16 Manitoba Centre for Health Policy
Conclusions (2)
• Some TB Registry case and contact data are incomplete
• Onset of cough missing from >50% of respiratory TB
cases and therefore cannot be used to develop
measures about care delivery
• Contact investigation completion is not well defined and
therefore not interpretable
• Number of TB contacts per case is highest in northern First
Nations communities
• Completeness of TB contact investigations also highest
in northern communities
17 Manitoba Centre for Health Policy
Conclusions (3)
• Active TB cases are high users of the healthcare system:
– Hospitalization (including multiple days in hospital)
– ER visits
– Medical specialists
– Family physicians
– non-TB-related prescription medications
• Health care use of persons treated for LTBI is important
– Modest treatment completion rates leave room for
improvement
18 Manitoba Centre for Health Policy
Thank You / Questions
umanitoba.ca/centres/mchp
facebook.com/mchp.umanitoba
https://twitter.com/um_mchp (@um_mchp)
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